Drug and alcohol addiction are under the umbrella term of substance dependence in the DSM-V. ICD-10 includes them all under the heading Mental and behavioral disorders due to psychoactive substance use, which is coded from F10 to F19. In the early days of risk adjusted payments, we encountered many providers who were unwilling to “stigmatize” the substance-dependent patient with that diagnosis. The issue was so widespread that we blogged about it in 2011!
How the times have changed!
These days, we see a complete turnaround. In fact, the opposite is now true: providers diagnose dependence without documenting the requisite criteria that support this family of codes. The result is inflated risk scores that raise flags with Medicare Advantage plans and CMS, improperly increase funding which is subject to recoupment and saddle the patient with a diagnosis that is not valid. In recognition of September being National Alcohol & Drug Addiction Recovery Month, we thought a short reminder would be helpful.
Dependence is both a mental and physical state resulting from taking a drug. It is characterized by behavioral and other responses that always include a compulsion to consume a substance on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence.
DSM-V guidance on diagnosing substance dependence includes the requirement to document three or more criteria from this list:
- Using for longer than intended or in larger quantities than intended
- Wanting to decrease use but unable to do so
- Spending excessive time getting/using/recovering from substance use
- Giving up meaningful social and recreational activities because of use
- Continued use despite causing or worsening physical or psychological problems
- Needing larger quantities to achieve same desired effect (tolerance)
- Experiencing unpleasant symptoms in response to abrupt cessation of substance (withdrawal)
However, there is an important caveat: symptoms of tolerance and withdrawal occurring during appropriate medical treatment with prescribed medications are specifically not counted when diagnosing substance use disorder. This means that the patient with failed back surgery who has been on a steady dose of opioids for several years is not considered dependent if he is using the medications as prescribed.
If you would like a free copy of our Bulletin on Substance Use Disorders, please contact us.